PROGRESS FOR CHILDREN A REPORT CARD ON WATER AND SANITATION

Transcription

1 PROGRESS FOR CHILDREN A REPORT CARD ON WATER AND SANITATION NUMBER 5, SEPTEMBER 2006

2 CONTENTS 1 Foreword WATER, SANITATION AND THE MDGs 2 Water, Sanitation and Hygiene ESSENTIAL ELEMENTS OF A CHILD SURVIVAL STRATEGY West/Central Africa INCREASING NUMBERS WITH NO ACCESS Eastern/Southern Africa SLOW PROGRESS AMID EMERGENCIES Middle East/North Africa ON TRACK, BUT WATER IS SCARCE South Asia TWO IN THREE WITHOUT SANITATION East Asia/Pacific THE CHALLENGE OF URBANIZATION Latin America/Caribbean PROGRESS, YET PERSISTENT DISPARITIES 24 CEE/CIS POOREST CHILDREN LEFT BEHIND Industrialized Countries NEED FOR RENEWAL About the Data HOW PROGRESS IS MEASURED 28 Endnote THE WAY FORWARD 30 Table WATER AND SANITATION

3 WATER, SANITATION AND THE MDGs It is estimated that unsafe water and a lack of basic sanitation and hygiene every year claim the lives of more than 1.5 million children under five years old from diarrhoea. This tragic statistic underscores the need for the world to meet its Millennium Development Goal (MDG) commitment on water and sanitation: MDG 7, which aims to halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. But those who die are by no means the only children affected. Many millions more have their development disrupted and their health undermined by diarrhoeal or water-related disease. In all, more than 1 billion people do not have access to drinking water from improved sources, while 2.6 billion are without basic sanitation yet these foundations for healthy living are taken for granted by the majority of people on the planet. Water and sanitation are vital in themselves, but they are also key prerequisites for reducing child and maternal mortality (MDGs 4 and 5) and combating diseases (MDG 6). And they are key to reducing child undernutrition (MDG 1) and achieving universal primary education (MDG 2). Girls, especially, are likely to spend more time in school when they spend less time fetching water and when adequate sanitation facilities are available on school grounds. This report card, the fifth in a UNICEF series that monitors progress for children towards the MDGs, measures the world s performance in water and sanitation. It projects that, if current trends continue, the world is on track to meet the target for drinking water though some countries and regions are lagging behind but the target for sanitation appears distant. We cannot be satisfied with current performance. We cannot afford to lose the opportunity represented by the Millennium Agenda to transform the lives of the most vulnerable children. The benefits of improved drinking water and sanitation are evident and could be extended to so many more of the world s people, if only sufficient resources and resolve were dedicated to the task. It is hard to think of a more potent reason to redouble our efforts than the thought of more than 1.5 million children every year who will not live to see their fifth birthday. Ann M. Veneman Executive Director, UNICEF 1

4 WATER, SANITATION AND HYGIENE: ESSENTIAL ELEMENTS OF A CHILD SURVIVAL STRATEGY Meeting the MDG targets would save the lives of millions of children. Global trends towards the MDG water and sanitation targets With 83 per cent coverage of improved drinking-water sources in 2004, the world is on track to meet the MDG target of halving the proportion of people without access to safe drinking water by But to meet the sanitation target, it will have to double the rate of improvement since % Water is as fundamental to human life as the air we breathe. Yet, ironically, this essence of life can have an injurious impact if its source is not free from pollution and infection and the most likely pollutant is human faeces that have not been disposed of and have spread because of a lack of basic sanitation and hygiene. Young children are more vulnerable than any other age group to the ill effects of unsafe water, insufficient quantities of water, poor sanitation and lack of hygiene. Globally, 10.5 million children under the age of five die every year, with most of these deaths occurring in developing countries. Lack of safe water, sanitation and adequate hygiene contribute to the leading killers of children under five, including diarrhoeal diseases, pneumonia, neonatal disorders and undernutrition. 1 This means that Millennium Development Goal 7 to ensure environmental Target 89 sustainability and its associated 2015 targets of reducing by half the proportion of people without sustainable access to safe drinking water and basic sanitation are of vital relevance to children. MDG 7 is also crucial in relation to improving nutrition, education and women s status, and success in this field will thus play a major role in determining whether the world meets its MDG targets across the board. Globally, more than 125 million children under five years of age live in households without access to an improved drinking-water source, and more than 280 million children under five live in households without access to improved sanitation facilities. Every one of these children is a unique individual whose rights are infringed and whose health is threatened from birth by the lack of access to safe drinking water and basic sanitation. Hygiene, as well, is an indispensable part of the equation. The simple act of hand washing can have important implications for children s health and survival, by reducing morbidity and mortality related to diarrhoea, pneumonia and other infectious diseases. 80% 60% 40% Drinking-water coverage Sanitation coverage Target Coverage needed to meet the MDG target The solid lines show coverage levels in 1990 and Projected coverage if current trends continue Drinking water Those children and adults who depend on water from unprotected dug wells, rivers, lakes or streams for drinking are at risk of infection by waterborne diseases if sanitation is poor. Too few enjoy the safety and convenience of having water that has been treated under managed conditions piped into their homes or compounds. Between the two extremes are sources of drinking water that are more likely to be safe and are referred to as improved. 2 Among these are public standpipes, tube wells or boreholes, protected dug wells, protected springs and rainwater (see About the Data on page 27). 2

5 Industrialized countries, 0.24 million CEE/CIS, 35 million Middle East/North Africa, 44 million Latin America/Caribbean, 50 million East Asia/Pacific, 402 million Eastern/Southern Africa, 154 million Global sanitation coverage increased from 49 per cent in 1990 to 59 per cent in 2004, and about 1.2 billion people gained access to improved sanitation facilities over that period. Yet the world is not making sufficient progress to meet the MDG sanitation target. To do so, the rate of improvement over the past 15 years would have to double between now and If current trends continue, there will be 2.4 billion people, partly as a result of population growth, without basic sanitation in South Asia, 222 million West/Central Africa, 157 million What the numbers mean for children Of the approximately 120 million children born in the developing world each year, half will live in households without access to improved sanitation facilities and one fifth in households without access to improved drinking-water sources, at grave risk to their survival and development. More than 1 billion people are without access to improved drinking-water sources. The chart shows the regional breakdown. The most recent estimates by the Joint Monitoring Programme for Water Supply and Sanitation (JMP), a programme of the World Health Organization (WHO) and UNICEF, indicate that global coverage increased from 78 per cent in 1990 to 83 per cent in 2004, which means that more than 1.2 billion people gained access to improved drinking-water sources over that period. If the current trend continues, the world is on track to meet its MDG target (89 per cent) by 2015, 3 though more than a billion people were without access to improved drinking-water sources in 2004 and keeping pace with population growth remains a major challenge. Sanitation Some 2.6 billion people worldwide two in five do not have access to improved sanitation, and about 2 billion of these people live in rural areas. Barely more than one third of the population uses adequate sanitation facilities in West/Central Africa (36 per cent), South Asia (37 per cent) and Eastern/Southern Africa (38 per cent). Improved sanitation facilities are those that reduce the chances of people coming into contact with human excreta and are likely to be more sanitary than unimproved facilities. 4 These include toilets that flush waste into a piped sewer, septic tank or pit, as well as dry pit latrines constructed with a cover. Such facilities are only considered to be improved if they are private rather than shared with other households (see About the Data on page 27). Unsafe drinking water, inadequate availability of water for hygiene and lack of access to sanitation together contribute to about 88 per cent of deaths from diarrhoeal diseases, 5 or more than 1.5 million of the 1.9 million children under five who perish from diarrhoea each year. This amounts to 18 per cent of all under-five deaths and means that more than 5,000 children are dying every day as a result of diarrhoeal diseases. 6 Diarrhoea s impact is particularly severe in children. Acute diarrhoea, as occurs with cholera, if left untreated can cause death within a day or less. Diarrhoeal diseases are transmitted through human excreta, and it is therefore critically important to have effective barriers in place to prevent this major transmission route. Improved sanitation alone could reduce diarrhoea-related morbidity by more than a third; improved sanitation combined with hygiene awareness and behaviours could reduce it by two thirds. 7 Such behaviours include consistent use of a toilet or latrine by each person in the household, safe disposal of young children s faeces, and hand washing with soap or ash after defecation and before eating. 8 Undernutrition, which is associated with more than half of all under-five deaths, 9 is closely linked to diarrhoea. Infectious diseases, and diarrhoea in particular, are the main determinants of wasting and stunting of growth in children in developing countries. 10 Low child mortality and high levels of water and sanitation provision are connected. Historical analysis of how diarrhoea mortality 3

6 Regional trends towards the MDG water target Four developing regions Middle East/North Africa, South Asia, East Asia/Pacific and Latin America/Caribbean are on track to halve the proportion of people without access to safe drinking water by West/Central Africa, Eastern/Southern Africa and CEE/CIS will need to step up progress to meet the target. 100% 80% 60% 40% 20% 0% Regional trends towards the MDG sanitation target Middle East/North Africa, East Asia/Pacific and Latin America/Caribbean are on track to meet the target of halving the proportion of people without access to basic sanitation. West/Central Africa, Eastern/Southern Africa and CEE/CIS are not on track, and South Asia has made progress but not enough to reach the target. 100% 80% 60% 40% 20% 0% West/Central Africa Eastern/Southern Africa Middle East/North Africa South Asia East Asia/Pacific Latin America/Caribbean CEE/CIS The solid lines show coverage levels in 1990 and Dotted lines show progress that will need to be made to reach the targets. was virtually eradicated in Stockholm (Sweden) in the period up to 1925 suggests that, along with public education and the enforcement of sanitary laws and regulations, large-scale interventions expanding access to clean water had the greatest impact when implemented as part of a broader package that included improved sanitation. 11 Diarrhoea is, however, far from being the only problem. Pneumonia takes more than 2 million young children s lives every year, 12 and recent studies suggest that hand washing with soap may help reduce the incidence of childhood pneumonia, as well as diarrhoea, in the developing world. 13 Careful and frequent hand washing is recommended, too, as a means of preventing the transmission of avian influenza, among other infectious diseases. Water, sanitation and hygiene are associated with other diseases, such as trachoma, and worm-related illnesses, including Guinea worm disease (dracunculiasis), bilharzia (schistosomiasis) and those caused by intestinal worms (ascariasis and hookworm). In children, worm infestation can occur at vital stages in their intellectual and physical development. Worm infestations predominately affect children of school age from 5 to 15 years old resulting in reduced physical growth, weakened physical fitness and impaired cognitive functions. 14 Poor nutritional status contributes to these effects. As the intensity of infection increases, academic performance and school attendance decline substantially. 15 Clean water and improved sanitation can reduce the morbidity of dracunculiasis and schistosomiasis by more than three quarters. 16 Dracunculiasis is today at the point of eradication its worldwide prevalence has been reduced from an estimated 3.5 million cases in 1986 to about 10,000 reported cases in Endemic in 20 countries in the late 1980s, Guinea worm is now endemic in just 9 African countries: Burkina Faso, Côte d Ivoire, Ethiopia, Ghana, Mali, Niger, Nigeria, Sudan and Togo. 17 Safe water: region-by-region progress In assessing progress, four developing regions East Asia/Pacific, Middle East/North Africa, South Asia and Latin America/Caribbean are on track to meet their MDG targets for safe water. But the current progress rates in sub- Saharan Africa and in Central and Eastern Europe and the Commonwealth of Independent States (CEE/CIS) will leave those regions short. 4

7 About 2.6 billion people are without access to improved sanitation facilities. The chart shows the regional breakdown. Industrialized countries, 2 million CEE/CIS, 63 million Middle East/North Africa, 96 million Latin America/Caribbean, 124 million East Asia/Pacific, 944 million The remarkable progress in South Asia and Latin America/Caribbean has placed them on the verge of achieving their drinking-water goals 10 years early. In both regions, the number of people without access shrank between 1990 and 2004 in South Asia from 326 million to 222 million and in Latin America/ Caribbean from 74 million to 50 million. South Asia, 921 million West/Central Africa, 225 million Eastern/Southern Africa, 215 million Although West/Central Africa s drinking-water coverage improved from 49 per cent in 1990 to 55 per cent in 2004, it needs to reach a far target of 75 per cent by The total number of people in the region without access to improved drinking-water sources actually increased over the period. In Eastern/Southern Africa, the situation for access to drinking water is similar, as the region improved coverage from 48 per cent in 1990 to 56 per cent in 2004 but faces a target of 74 per cent. In CEE/CIS, meanwhile, coverage has stagnated at 91 per cent; its 2015 goal is 96 per cent. Sub-Saharan Africa represents about 11 per cent of the world population, but almost a third of all people without access to safe drinking water live here. High fertility rates in sub-saharan Africa translate to 54 million children under five without access to an improved drinking-water source, or about 40 per cent of the world s more than 125 million young children without access. The comparable numbers are negligible in the industrialized world and 3 million in CEE/CIS. Basic sanitation: region-by-region progress Three regions are on track to meet their MDG targets for basic sanitation: Latin America/ Caribbean, East Asia/Pacific and Middle East/ North Africa. The largest gains have been made in South Asia, where access to improved sanitation facilities more than doubled from 17 per cent in 1990 to 37 per cent in 2004, and in East Asia/Pacific, where it rose from 30 per cent to 51 per cent. These improvements were primarily driven by gains made in India and China. In India, sanitation coverage more than doubled from 14 per cent in 1990 to 33 per cent in 2004, while in China sanitation coverage increased from 23 per cent to 44 per cent over the same period. But the majority of the people in both of these highly populated countries still remain without access. The least progress was made in CEE/CIS, where coverage froze at 84 per cent, and in Eastern/Southern Africa where access improved only slightly, from 35 per cent in 1990 to 38 per cent in 2004, and where with population growth, the absolute number of people without sanitation increased by a third over the same period. The numbers of children affected by inadequate sanitation vary widely between regions. Of the more than 280 million children under five living in households without access to improved sanitation facilities, almost two thirds live in South Asia (106 million) and sub- Saharan Africa (75 million). Again, these figures compare with negligible numbers of unserved children in the industrialized world and 6 million in CEE/CIS. Disparities Among the largest disparities in safe water and basic sanitation are those between urban and rural populations. Globally, access to improved drinking-water sources is 95 per cent in urban areas, compared with 73 per cent in rural areas. The urban-rural divide in drinking water is at its widest in sub-saharan Africa, where 81 per cent of people in urban areas are served, compared with 41 per cent in rural areas. Moreover, of the more than 1.2 billion people who gained access to improved drinking-water sources over the period , nearly two thirds lived in urban areas. Notwithstanding this, the pace of urbanization is such that the absolute number of people without access to drinking water increased by 63 million in urban areas, doubling in sub-saharan 5

8 West/Central Africa Eastern/Southern Africa Middle East/North Africa South Asia East Asia/Pacific Latin America/Caribbean CEE/CIS 40 0% 20% 40% 60% 80% 100% Access to improved drinking-water sources, 2004 Globally, 95 per cent of people living in urban areas and 73 per cent of people living in rural areas have access to improved drinking-water sources. The largest regional disparities are found in sub-saharan Africa Africa and quintupling in East Asia/Pacific. Of the more than 1 billion people who remain without access to improved drinking water, about 900 million live in rural areas, where journeys to collect water tend to be longer than in urban areas. Three quarters of the world s rural population must collect water from a communal source, 18 and they must collect sufficient amounts not only for drinking but for the cooking and washing needs of the whole family. In UNICEFsupported Multiple Indicator Cluster Surveys (MICS) in 23 countries, about half of households surveyed spend more than 30 minutes per trip collecting water, while more than a fifth spend more than an hour on each trip. 19 And there are signs that collection times have increased in some urban areas. 20 In periurban areas and slums, irregular or interrupted supplies may cause residents to wait up to several hours before they can collect water. Urban sanitation coverage worldwide was more than twice as high as rural coverage in per cent in urban areas, compared with 39 per cent in rural areas. Of the 2.6 billion people currently without access to Urban Rural basic sanitation, 2 billion live in rural areas. The urban-rural disparity is largest in South Asia, where 63 per cent of the urban population versus 27 per cent of the rural population is served. Only in industrialized countries is urban and rural coverage about the same. The urban-rural divide is not the only disparity evident in access to water and sanitation: An analysis of 20 recent Demographic and Health Surveys showed that the richest quintile is four times more likely to have access to sanitation than the poorest quintile. 21 There is also an associated gender gap. Women and girls bear more of the consequences of poor water, sanitation and hygiene, as they are usually the ones who fetch the water and care for the children and other household members who fall sick from water-related diseases. In addition, girls school attendance is affected the most by inadequate water and sanitation facilities in schools and by time spent travelling long distances to drinking-water sources. Girls and women need greater privacy for personal hygiene than men. In the absence of private sanitation facilities, there have been cases where women limit their food and water intake so they can relieve themselves under cover of darkness; yet night-time trips to fields or roadsides may put them at risk of physical attack. 22 Water, sanitation and hygiene in schools Unsafe water and unhygienic conditions not only have a detrimental effect on the health of under-fives but also have an impact on the health, attendance and learning capacities of school-age children. UNICEF is promoting an additional target alongside those of the MDGs, which is to ensure that all schools have adequate childfriendly water and sanitation facilities, along with hygiene-education programmes. The Plan of Implementation of the World Summit on Sustainable Development in 2002 emphasized sanitation in schools as a priority action, while the Thirteenth Session of the United Nations Commission on Sustainable Development in 2005 reiterated this position and also emphasized the need for hygiene education in schools. Providing adequate water and sanitation in schools is essential if the enrolment, learning and retention of girls is to improve and is key to meeting MDGs 2 and 3. Lack of 6

9 Access to improved sanitation facilities, 2004 Globally, 80 per cent of people living in urban areas and 39 per cent of people living in rural areas have access to improved sanitation facilities. The largest regional disparities are found in South Asia. West/Central Africa Eastern/Southern Africa Middle East/North Africa South Asia appropriately private and sanitary facilities has a greater impact on girls than boys, contributing to decisions on whether they ever attend, and then influencing how long they stay in school. Girls sometimes do not attend school during menstruation or drop out at puberty because of a lack of sanitation facilities that are separate for girls and boys in schools. In addition, adolescent girls are particularly at risk of anaemia aggravated by parasitic infections and iron stress when sanitation is inadequate or unavailable at school or in the home. 23 All children perform better and have enhanced self-esteem in a clean, hygienic environment. Properly used and maintained sanitation facilities and an adequate supply of water for personal hygiene and hand washing prevent infections and infestations, while also contributing to overall public health and environmental protection. Programmes that combine improved sanitation and hand-washing facilities with hygiene education in schools can improve the health of children for life and can promote positive change in communities. Field Urban Rural assessments show that teaching children the importance of hand washing and other good hygiene habits promotes increased knowledge and positive behaviour change, especially when the schools are equipped with an adequate number of safe toilets or latrines and sufficient water for washing. 24 Water and sanitation in emergencies Children affected by natural disasters, conflict and instability have the same rights as children everywhere. Water, sanitation and hygiene activities are vital in these circumstances. Although the provision of water may take precedence in the early stages of an emergency, sanitation and hygiene inputs are critically important. Beyond the initial response, all three elements water, sanitation and hygiene need to be developed both at a general level and in particular at schools and health posts. The growing number, frequency and severity of emergencies particularly in the past two decades underline the compelling importance of water, sanitation and hygiene to overall humanitarian responses. But too often, support has come up short, or was too late, resulting in an uncoordinated and ineffective response. A renewed interest in the sector, coupled with a vision of a better response capacity through cluster arrangements, provides a unique opportunity to address past constraints and weaknesses. The stage is now set for sound planning, preparedness and predictability; greater coherence to a system-wide approach; and more effective collaboration and coordination among partners elements that will lead to more timely and effective responses in future humanitarian crises. 27 East Asia/Pacific Latin America/Caribbean CEE/CIS % 20% 40% 60% 80% 100% 7

10 THE WORLD IS ON TRACK TO MEET THE MDG WATER TARGET The MDG target is to halve, by 2015, the proportion of people without sustainable access to safe drinking water. An analysis of the most recent estimates by the WHO/ UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) for the period shows that 75 developing countries are on track to reach the target, 5 have made progress, though insufficient to reach the target, and 23 are not on track. In 41 developing countries, data were insufficient to estimate trends. 8

11 On track: Coverage in 2004 was less than 5 per cent below the rate it needed to be for the country to reach the MDG target, or coverage was 95 per cent or higher. Progress but insufficient: Coverage in 2004 was 5 per cent to 10 per cent below the rate it needed to be for the country to reach the MDG target. Not on track: Coverage in 2004 was more than 10 per cent below the rate it needed to be for the country to reach the MDG target, or the trend shows unchanged or decreasing coverage. Insufficient data: Data were insufficient to estimate trends. Note: The MDG drinking-water targets in this map and in the table on pages are expressed as the proportion of the population using improved drinking-water sources. These targets are calculated by adding half of the proportion of the population not using improved drinking-water sources in 1990 to the proportion of the population using improved sources in For countries without a 1990 baseline, MDG targets were calculated based on coverage in 1995 (where such estimates were available), on the assumption that from the countries were on track to reach the MDG target. On track, progress but insufficient and not on track classifications were calculated by comparing actual coverage rates in 2004 with the coverage rate the country should have had in 2004 if it was on track to reach the MDG target. This map is stylized and not to scale. It does not reflect a position by UNICEF on the legal status of any country or territory or the delimitation of any frontiers. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. 9

12 THE WORLD HAS MADE INSUFFICIENT PROGRESS TOWARDS THE MDG SANITATION TARGET The MDG target is to halve, by 2015, the proportion of people without sustainable access to basic sanitation. An analysis of the most recent estimates by the WHO/ UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) for the period shows that 50 developing countries are on track to reach the target, 4 have made progress, though insufficient to reach the target, and 41 are not on track. In 49 developing countries, data were insufficient to estimate trends. 10

13 On track: Coverage in 2004 was less than 5 per cent below the rate it needed to be for the country to reach the MDG target, or coverage was 95 per cent or higher. Progress but insufficient: Coverage in 2004 was 5 per cent to 10 per cent below the rate it needed to be for the country to reach the MDG target. Not on track: Coverage in 2004 was more than 10 per cent below the rate it needed to be for the country to reach the MDG target, or the trend shows unchanged or decreasing coverage. Insufficient data: Data were insufficient to estimate trends. Note: The MDG sanitation targets in this map and in the table on pages are expressed as the proportion of the population using improved sanitation facilities. These targets are calculated by adding half of the proportion of the population not using improved sanitation facilities in 1990 to the proportion of the population using improved facilities in For countries without a 1990 baseline, MDG targets were calculated based on coverage in 1995 (where such estimates were available), on the assumption that from the countries were on track to reach the MDG target. On track, progress but insufficient and not on track classifications were calculated by comparing actual coverage rates in 2004 with the coverage rate the country should have had in 2004 if it was on track to reach the MDG target. This map is stylized and not to scale. It does not reflect a position by UNICEF on the legal status of any country or territory or the delimitation of any frontiers. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. 11

14 WEST/CENTRAL AFRICA: INCREASING NUMBERS WITH NO ACCESS The region has the lowest coverage of improved drinking water and sanitation in the world, and the numbers of unserved were higher in 2004 than in Coverage improved very slowly between 1990 and 2004, from 49 per cent to 55 per cent in access to improved drinking-water sources and from 28 per cent to 36 per cent in access to improved sanitation facilities. These small rates of increase failed to keep pace with the expanding population in the region. The absolute number of people without access to drinking water increased from 124 million to 157 million, and the number without sanitation from 173 million to 225 million. Although 75 million people gained access to improved drinking-water sources between 1990 and 2004, a further 147 million, or around 15 million a year, will need to gain access between now and 2015 if the MDG target is to be met. Similarly, although 56 million people benefited for the first time from improved sanitation between 1990 and 2004, another 165 million, or about 17 million a year, must be reached between now and 2015 to achieve the MDG target. If current trends continue and the rate of progress does not improve, about 260 million people in the region will be without access. The water and sanitation position in West/ Central Africa is of particular urgency, as the region has the highest under-five mortality rate of all developing regions: 191 child deaths per 1,000 live births. Recurrent outbreaks of cholera in both urban and rural areas underline the poor state of this region s basic living conditions. The majority of the region s population remains based in rural areas, but urbanization is increasing fast. About 49 million people living in urban areas gained access to improved drinking-water sources from 1990 to 2004 (compared with only 26 million people living in rural areas). Yet this increase was unable to match the expanding urban population, and the number of people without access in urban areas doubled, from 17 million to 34 million. Coverage of improved drinking-water sources is less than 50 per cent in five countries of West/Central Africa. Nigeria Democratic Republic of the Congo Niger 46 Equatorial Guinea 43 Chad 42 0% 10% 20% 30% 40% 50% 12

15 There are still five countries in West/Central Africa where less than half of the population has access to improved drinking-water sources: Chad (42 per cent), Equatorial Guinea (43 per cent), the Democratic Republic of the Congo (46 per cent), Niger (46 per cent) and Nigeria (48 per cent). The Democratic Republic of the Congo and Nigeria have particularly low coverage in rural areas (29 per cent in the Democratic Republic of the Congo and 31 per cent in Nigeria). areas), Burkina Faso (42 per cent, compared with 6 per cent) and Liberia (49 per cent, compared with 7 per cent). The eradication of dracunculiasis or Guinea worm, a disease spread through the use of contaminated water, is a priority. The West/ Central Africa region contains seven of the nine remaining countries in which Guinea worm disease is endemic. Ghana reported nearly 4,000 cases in 2005, or 79 per cent of Burkina Faso, Liberia and Niger have the largest urban-rural disparities in access to improved sanitation facilities in West/Central Africa. Liberia 7 49 Niger 43 4 Burkina Faso 42 6 Urban Rural 0% 10% 20% 30% 40% 50% Nonetheless, some countries merit notice for their progress in increasing access to improved drinking-water sources between 1990 and Burkina Faso, for example, boosted its coverage from 38 per cent to 61 per cent, while Chad improved from 19 per cent to 42 per cent and they are among nine countries in the region on track to meet the MDG water target. 25 Only 4 of the region s 24 countries have reached more than half their population with improved sanitation facilities: Senegal (57 per cent), Equatorial Guinea (53 per cent), Gambia (53 per cent) and Cameroon (51 per cent). Senegal is, moreover, the only country in the region currently on track to attain the MDG sanitation target, although both Benin and the Democratic Republic of the Congo made considerable progress from a very low base. Between 1990 and 2004, Benin improved its coverage from 12 per cent to 33 per cent and the Democratic Republic of the Congo from 16 per cent to 30 per cent. cases in the region. Nigeria, however, reported only 120 cases in Civil strife and the resulting refugee and internally displaced populations have strained resources in the region and slowed progress in water and sanitation coverage. Restoring safe water, sanitation and hygiene to children and their families is a priority following natural disasters such as the floods in Mali in recent years, as well as during conflicts such as that in Côte d Ivoire from 2002 onward and major humanitarian crises such as those in the Democratic Republic of the Congo and Liberia. Urban-rural disparities in sanitation are particularly large in Niger (43 per cent in urban areas, compared with 4 per cent in rural 13

16 EASTERN/SOUTHERN AFRICA: SLOW PROGRESS AMID EMERGENCIES The region faces some of the lowest water and sanitation coverage rates in the world. Progress in both water and sanitation coverage during the 1990s was slow. In 2004, just 56 per cent of the region s people had access to improved drinking-water sources, up from 48 per cent in 1990 but well short of the 2015 target of 74 per cent, and 38 per cent had access to improved sanitation facilities, up slightly from 35 per cent in Although 74 million people gained access to improved drinking-water sources between 1990 and 2004, the increase in coverage did not keep pace with population growth. As a result, the number of people without improved drinking-water sources increased from 129 million to 154 million. A further 129 million, or around 13 million a year, will need to gain access by 2015 if the MDG target is to be met. In sanitation, the increase in coverage was not sufficient to match population growth, and the number of people without coverage increased from 162 million to 215 million. To meet the 2015 target of 68 per cent coverage, a further 163 million, or around 16 million a year, will need to gain access. The under-five mortality rate in Eastern/ Southern Africa is 149 child deaths per 1,000 live births, the second largest in the developing world after West/Central Africa, so these issues are of critical importance. Flood and drought emergencies in the region are cyclical and often catastrophic. During 2006, major international humanitarian assistance was required for 8 million people whose lives were threatened in droughtstricken areas of Djibouti, Eritrea, Ethiopia, Kenya and Somalia including around 1.6 million children under five. Because of climate shifts, what was once a 10-year Urban-rural disparities in access to improved drinking-water sources are higher in Eastern/Southern Africa than in any other region. Zambia Ethiopia Madagascar Mozambique 72 Urban 26 Rural 0% 20% 40% 60% 80% 100% 14

17 100% 80% 60% 40% 20% Malawi Mozambique Madagascar The best performers in sanitation over this period were Madagascar (which improved from 14 per cent to 34 per cent), Malawi (from 47 per cent to 61 per cent) and Mozambique (from 20 per cent to 32 per cent), though Malawi is the only one of the region s 22 countries actually on track to meet the MDG target. Two countries of the Horn of Africa Ethiopia and Somalia require the most urgent attention, with coverage in improved drinkingwater sources of 22 per cent in Ethiopia and 29 per cent in Somalia, and in basic sanitation of just 13 per cent in Ethiopia and 26 per cent in Somalia. Both countries also have especially large populations, high under-five mortality rates and low levels of school attendance. School sanitation is a particular priority in poor rural areas, as it is in Eritrea, where sanitation coverage stands at a mere 9 per cent. 0% Madagascar, Malawi and Mozambique made the largest gains in providing access to improved sanitation facilities in Eastern/Southern Africa, drought cycle in the Horn of Africa has now been abbreviated to between three and five years. In addition, cholera a waterborne disease remains a severe threat. There were recent outbreaks in several countries, including Burundi, Malawi and Mozambique in 2005 and Angola, Kenya and Malawi in The halfmillion cholera cases suffered in Eastern/ Southern Africa between 1997 and 2000 exceeded the numbers in the rest of the world combined. 27 Lack of water and sanitation at school is a problem in many countries of Eastern/ Southern Africa, and in schools in some areas, more than 150 children must share one latrine. 29 There are major successes in this field, however. Malawi, for example, has cut costs for school water and sanitation packages by two thirds 30 and introduced facilities for girls, while Uganda improved attendance and lowered drop-out rates for girls after introducing female-only washrooms. 31 In Kenya murals or talking walls in schools have proved to be effective in delivering hygiene messages to students, while in South Africa schools have introduced playpumps specially designed roundabout pumps delivering water while children use them for play. Urban-rural disparities in access to improved drinking-water sources are large with 86 per cent coverage in urban areas, compared to just 42 per cent in the countryside. These disparities are greatest in Ethiopia, with 81 per cent coverage in urban areas and 11 per cent coverage in rural areas. As always, the overall regional picture masks the diverse experiences of individual countries, some of which have made huge strides over the past 15 years. Malawi, for example, boosted drinking-water coverage from 40 per cent to 73 per cent in the period, and Namibia s coverage rose from 57 per cent to 87 per cent. Both countries have already surpassed their 2015 targets. Eleven other countries are also on track to meet their drinking-water targets

18 MIDDLE EAST/NORTH AFRICA: ON TRACK, BUT WATER IS SCARCE Progress started at relatively high levels, but it has been slow. The region should, however, meet both the water and sanitation targets. More good news is that the Middle East/ North Africa region reduced its under-five mortality rate by nearly a third, from 81 child deaths per 1,000 live births in 1990 to 56 in But water is an increasingly precious commodity in this arid region, and as the population grows, the link between environmental degradation, water scarcity and conflict is becoming a mounting threat. Algeria, Djibouti, Qatar, Saudi Arabia, Tunisia, the United Arab Emirates and Yemen had already experienced water scarcity by 1990; Egypt, Iran, the Libyan Arab Jamahiriya, Morocco, Oman and the Syrian Arab Republic are projected to be water-scarce by The prospect jeopardizes the region s position in relation to the MDG water target, and it underlines the urgent need for countries to manage their water resources sustainably. Although more than half the countries in the Middle East/North Africa with data sufficient to estimate trends are on track to meet the drinking-water target, in the region as a whole, access to improved drinking-water sources increased only marginally, from 86 per cent in 1990 to 88 per cent in And the number of people without access increased from 39 million to 44 million over this period. Among them, some 34 million live in rural areas, about the same number as in But there are almost twice as many urban dwellers without safe water in 2004 as there were in Urban-rural disparities in water are particularly pronounced in Morocco (99 per cent urban to 56 per cent rural). More than 40 per cent of rural dwellers in Djibouti, Iraq and Morocco have no access to improved drinking-water sources. Data for Sudan refer to the situation in the northern part of the country, where two out of three rural dwellers have access to improved drinking-water sources. Access is much lower when taking into account the entire country, including desert areas with a regular movement of nomadic populations. There was slightly more progress in the Middle East/North Africa on sanitation coverage, from 68 per cent in 1990 to 74 per cent in 2004, with 87 million people gaining access and the MDG sanitation target of 84 per cent is likely to be achieved. Over this period, however, the number of people without access actually increased, from 88 million in 1990 to 96 million in To reach the target, a further 107 million people In rural areas of Djibouti, Iraq and Morocco, coverage of improved drinking-water sources is less than 60 per cent. The chart shows rural-area coverage in Djibouti Morocco Iraq 50 0% 10% 20% 30% 40% 50% 60% 16

19 must be reached by 2015, at an average of around 11 million a year. Urban-rural disparity in sanitation coverage is sizeable, at 90 per cent and 53 per cent, respectively; in Yemen, access for urban populations is three times higher than for rural populations. Disparities exist in middleincome countries as well, including Djibouti, Egypt, Morocco and Tunisia. logistical problems and security concerns make repairs of local water and sanitation systems difficult. An estimated 25 per cent of child deaths in Iraq are due to waterrelated diseases. 34 In Sudan s Darfur region, helping conflictaffected children and their families and communities remains a UNICEF priority, as it was for many years in the conflict areas in Egypt, Morocco and the Syrian Arab Republic had the largest increases in access to improved sanitation facilities in the Middle East/North Africa, % 80% 60% 40% 20% 0% Syrian Arab Republic Morocco Egypt The largest increases in drinking-water coverage during were recorded in the Syrian Arab Republic (up from 80 per cent to 93 per cent) and Tunisia (81 per cent to 93 per cent). The region s lowest coverage levels are found in Yemen (67 per cent), Sudan (70 per cent) and Djibouti (73 per cent). the south of the country, where well drilling, sanitation and hygiene education have all been of the utmost importance. Because the country contains more than 5,000 cases of Guinea worm about half of all remaining cases in the world Sudan is the front line in the battle to eliminate the disease. The biggest improvements in sanitation coverage between 1990 and 2004 were made in Egypt (from 54 per cent to 70 per cent), Morocco (from 56 per cent to 73 per cent) and the Syrian Arab Republic (from 73 per cent to 90 per cent), which are among the 10 countries in the region on track to meet the MDG sanitation target. 33 Conflict-related emergencies remain a major concern. The priority is to send drinking water directly to families in need and to rehabilitate damaged water and sanitation systems. In Iraq, where coverage since 1990 has declined for both drinking water and sanitation, children continue to suffer as 17

20 SOUTH ASIA: TWO IN THREE WITHOUT SANITATION The region has made progress in both water and sanitation, but low levels of sanitation remain one of its biggest public-health threats. India and Nepal have already met the MDG target on water, and Pakistan has virtually achieved it. The chart shows progress, % 80% 60% 40% 20% 0% South Asia s sanitation coverage is among the lowest in the world, at 37 per cent, about the same as that in sub-saharan Africa. In four of the region s eight countries including the most populous country, India barely more than one third of people have access to improved sanitation facilities. The situation is of particular concern for the region s children. Under-five mortality in South Asia, at 92 child deaths per 1,000 live births, is the highest in the developing world outside sub-saharan Africa, where the rate is 171 per 1,000 live births. The region has boosted access to improved drinking-water sources from 71 per cent in 1990 to 85 per cent in 2004 and has virtually met its MDG target of 86 per cent. The absolute number of people in the region without improved drinking-water sources has declined by about a third, from 326 million in 1990 to 222 million in Some 445 million Pakistan Nepal India people gained access over the period, 88 per cent of them in India and Pakistan. But a further 243 million, around 24 million a year, need to be reached by 2015 if the target is to be met. The proportional increase in access to improved sanitation facilities in South Asia has been even greater than that in drinking water. The rate has more than doubled, from 17 per cent in 1990 to 37 per cent in 2004, but it started from such low levels that the pace will have to be considerably accelerated if the region is to meet its MDG target of 59 per cent. A further 478 million people, around 48 million a year, will need to gain access by The region s sanitation coverage is on a par with sub-saharan Africa s, and its 921 million people who live without any toilet facilities represent more than a third of the world s total. Nevertheless, it should be noted that four of the eight countries in the region are on track to meet the MDG sanitation target including Sri Lanka, which has already exceeded its target, achieving outstanding expansion from 69 per cent coverage in 1990 to 91 per cent by In sanitation coverage, South Asia has the most severe urban-rural disparities in the world. And while the number of people in urban areas without access to sanitation increased from 139 million in 1990 to 153 million in 2004, urban populations are more than twice as likely as rural populations to have access to sanitation. In India, the difference is even greater, at 59 per cent for urban dwellers compared to 22 per cent for their rural counterparts. This leaves 600 million people living in rural India without basic sanitation. In contrast, for access to improved drinkingwater sources, South Asia almost halved the urban-rural gap from In rural 18

21 Maldives Pakistan Nepal India Bangladesh Afghanistan 49 Urban 29 Rural 0% 20% 40% 60% 80% 100% Urban-rural disparities in access to improved sanitation facilities in South Asia are the largest in the world. areas, coverage increased from 65 per cent to 81 per cent, a surge due primarily to progress in India. Of the eight countries in the region, India and Nepal have already met the MDG water target, and Pakistan has virtually achieved it. Pakistan has also made notable improvements in sanitation, increasing its coverage from 37 per cent to 59 per cent; advances in rural areas were particularly marked, as coverage rose from 17 per cent in 1990 to 41 per cent in Access to improved drinking-water sources in Afghanistan has increased from 4 per cent in 1990 to 39 per cent in Although this upgrade is remarkable, it still leaves Afghans with the world s third-lowest access to improved drinking-water sources. The rural population is, moreover, half as likely to have access as that in urban areas (31 per cent compared with 63 per cent). Given that 76 per cent of Afghanistan s population lives in the countryside, maintaining the recent pace of progress will be a challenge. Sanitation coverage has also improved dramatically in Afghanistan, from 3 per cent in 1990 to 34 per cent in 2004, so it is broadly on a par with that in India and is approaching the regional average. In many areas of South Asia, however, naturally occurring arsenic and fluoride contamination are threatening to reverse the gains made in providing improved drinking water. Unsafe levels of arsenic have been detected in Bangladesh, India, Nepal, Pakistan and other countries. The problem is greatest in Bangladesh, where it was discovered that more than 30 per cent of the tube wells sunk in recent decades are contaminated with arsenic above the nationally recommended level. (The drinking-water access figures for Bangladesh in this report have been discounted for the percentage of tube wells contaminated with arsenic.) UNICEF s response in Bangladesh has been to partner with the government and nongovernmental organizations to raise awareness about arsenic poisoning, to test water sources (safe wells are painted green and unsafe ones red), to improve patient health care and to help provide alternative safe-water options. Around 84,000 new water points have been installed to date in highly arsenic-affected areas, serving millions of people. 19